Is Discussing the Safety of Vaccines the Third Rail of Pediatrics?

Absolutely the most common questions I get from parents are about immunizations. This has become the dominant topic of conversation at all well-child visits beginning with the very first visit after birth. In fact, at my monthly prenatal group sessions, it has become the first question without fail. Honestly, I welcome the dialogue. To me, it simply means that new and prospective parents—bombarded by information from relatives, friends and the media—care so much about this tremendously important medical decision that they want to thoroughly review the risks and benefits in order to make the most informed decision they can. I know, too, that I am not the only pediatrician having these discussions. I’ve heard from many colleagues that they are spending more time than ever answering questions about immunizations. Sadly, though, an increasing number of pediatricians are opting out of these discussions and are “firing” families who decide—based on religious, philosophical or medical reasons—to not vaccinate their children. In a recent on-line poll conducted by Contemporary Pediatrics, nearly 50 percent of pediatricians responded that they would indeed dismiss from their practices those families who refused to vaccinate. The poll was triggered by a Wall Street Journal article (“More Doctors ‘Fire’ Vaccine Refusers,” February 15, 2012) covering the trend:

Pediatricians fed up with parents who refuse to vaccinate their children out of concern it can cause autism or other problems increasingly are “firing” such families from their practices, raising questions about a doctor’s responsibility to these patients. Medical associations don’t recommend such patient bans, but the practice appears to be growing, according to vaccine researchers. In a study of Connecticut pediatricians published last year, some 30% of 133 doctors said they had asked a family to leave their practice for vaccine refusal, and a recent survey of 909 Midwestern pediatricians found that 21% reported discharging families for the same reason. By comparison, in 2001 and 2006 about 6% of physicians said they “routinely” stopped working with families due to parents’ continued vaccine refusal and 16% “sometimes” dismissed them, according to surveys conducted then by the American Academy of Pediatrics.

In fact, the AAP policy on vaccine refusal is quite clear, and the excerpts below are well worth reading closely.

What is the pediatrician to do when faced with a parent who refuses immunization for his or her child? First and most important, the pediatrician should listen carefully and respectfully to the parent’s concerns, recognizing that some parents may not use the same decision criteria as the physician and may weigh evidence very differently than the physician does. Vaccines are very safe, but they are not risk free; nor are they 100% effective. This poses a dilemma for many parents and should not be minimized. The pediatrician should share honestly what is and is not known about the risks and benefits of the vaccine in question, attempt to understand the parent’s concerns about immunization, and attempt to correct any misperceptions and misinformation.

—————–

For all cases in which parents refuse vaccine administration, pediatricians should take advantage of their ongoing relationship with the family and revisit the immunization discussion on each subsequent visit. As respect, communication, and information build over time in a professional relationship, parents may be willing to reconsider previous vaccine refusals.

—————–

In general, pediatricians should avoid discharging patients from their practices solely because a parent refuses to immunize his or her child.

—————–

I have highlighted this last sentence. I strongly believe that the right of a parent to make health care decisions should be respected unless the child’s health is in immediate and grave danger. The ethical principles involved in these decisions are complex and vary from case-to-case. To have a blanket policy dismissing all families who refuse vaccination, I believe, is not the right choice. I know my view on this differs from many other pediatricians—we have families seeking to join our practice simply in order to have a conversation about the risks and benefits of vaccination. Most—I’d estimate well over 75 percent—decide after our conversations to begin immunizing their children. What would they have done otherwise? Check out of the medical system entirely? That might seem drastic, but I’ve seen this happening more lately. I have seen children who have not been to a pediatrician in years because the parents are afraid they’ll be chastised for their beliefs. Is this what’s best for their children? Talk about throwing the baby out with the bath water.

Instead of tossing families aside, maybe we should be asking why more and more are questioning vaccines and whether our modes of inquiry and communication regarding vaccine safety should be adjusted. As with so many of our American institutions designed to protect public good (CDC, EPA, FDA, etc.), the immunization program that is often termed “the greatest medical advancement of the last century” by public health figures and most doctors, may in fact be a victim of its own success. By that, I mean we have eliminated or vastly reduced most of the vaccine-preventable diseases that plagued our country in the 20th Century. The last case of naturally occurring paralytic polio in the United States was in 1979, and in fact, 95 percent of non-naturally occurring polio cases from 1980-1999 were vaccine-associated paralytic polio affecting some who received the oral Sabin vaccine. This vaccine was discontinued in the U.S. when it was discovered that the risk of polio from vaccination outweighed the natural risk of contracting polio; now we use the inactivated injectable Salk vaccine (the original polio vaccine) exclusively in our country. In a drastically changed infectious disease environment compared to 50 years ago, parents today are similarly trying to weigh risks versus benefits regarding vaccine efficacy and safety for all immunizations.

Do you think this is a radical statement? Shouldn’t parents have a role in this decision? Isn’t vaccination a medical procedure guided by the ethical principles of informed consent? Again, I understand there are other principles in play here—for example, what takes precedence, individual health or public health? Should a parent’s right to decide if and how to immunize her child be outweighed by society’s need to protect the community at large from outbreaks, including newborns and immunocompromised children who cannot receive certain vaccines? These are complex ethical principles and deserve measured, careful debate. I don’t think parents should be ridiculed and ousted for raising questions. But as a pediatrician who has dared to consider the idea that 100% of vaccines may not be safe and effective for every child all of the time (no different than any other medical intervention, I might add), I, too, have been labeled, at times, as “anti-vaccine.”

I’m not naïve. Despite the fact that I have been visibly, publicly in favor of immunization as public health policy, it is a common-place practice to marginalize those who question authority. Although I typically vaccinate children in my practice and (as I tell my patient’s families) I have vaccinated my children, because I question the rhetorical safety and efficacy of immunizations, special interest groups with lots of political power and money would like me to shut up. After all, if a board-certified pediatrician—a Fellow of the American Academy of Pediatrics—is voicing concern, well, I guess some find that threatening. I can deal with that; after all, it is my choice to speak out on the matter. It would be much easier to carry on in silence. But to attack parents who are just trying to make the best decisions they can for their kids? That’s not OK, and for those families, I cannot sit idly by.

In a country where we are trying to recover from one of the greatest economic debacles of all times due in part to a lack of regulatory oversight, is it wrong for parents to be cautious and skeptical? We live in a cynical age. Trust in public institutions is at an all time low. When one government regulatory agency—the CDC—is charged with both promoting vaccines and monitoring their safety, we have a big potential conflict of interest. What I have simply argued is that in order to save the vaccine program, we need transparency and open dialogue, not cloak-and-dagger policies. If parents are forced to choose between giving all currently mandatory vaccines on a strict schedule based more on insurance company recommendations and school requirements than on current scientific rationale, more are going to choose none and opt for full-scale exemptions. It is anecdotal, and I would love to study this, but it is my observation that most parents who are avoiding vaccination altogether would like to vaccinate their children against most illnesses, but have reservations about 1 or 2. In New Jersey, they are left with one option—religious exemption, and thereby effectively closing the door to any vaccines. Is this what we want?

We need to be able to ask very difficult questions—are immunizations in some way related to the epidemics of autism, food allergies, ADHD, and asthma afflicting our children? Are we trading off a reduction in acute, infectious-disease illnesses for a surge in chronic neurodevelopmental and atopic/autoimmune disorders? Even the stalwart academic vaccine advocate, the Mayo Clinic’s Dr. Gregory Poland, authored a landmark paper calling for the need to better understand the individual adverse responses to vaccine. Dr. Poland concludes, “Clearly more comprehensive studies are needed to determine if there are associations between genetic variations among individuals and susceptibility to serious adverse events in response to vaccination. These factors combined with technologic ability will lead to a new era in vaccinology and better, safer vaccines.” It will only be through open, scientifically-based debate that we will discover what is truly in the best interest of our public’s health. In the meantime, we must find a way to work with families who believe they are acting in their children’s best interests.

“The best way out is always through.”– Robert Frost, “A Servant to Servants” from “North of Boston” (1915)